Rachel Cooper on Classifying Madness and Diagnosing the DSM

On the future of mental health

The following interview is part of a “future of mental health” interview series that will be running for 100+ days. This series presents different points of view about what helps a person in distress. I’ve aimed to be ecumenical and included many points of view different from my own. I hope you enjoy it. As with every service and resource in the mental health field, please do your due diligence. If you’d like to learn more about these philosophies, services, and organizations mentioned, follow the links provided.

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Interview with Rachel Cooper

EM: You’ve written on the subject of “Is psychiatric classification a good thing?” Can you share with us some of your thoughts on that subject?

RC: Psychiatric classification has a range of effects—diagnoses can inform treatments, which might, or might not, be effective; they can be bureaucratically essential for accessing services or payments; they can change how people think about themselves and their actions. The effects of a diagnosis vary with the condition, the individual, and their situation. As such, I don’t think that there’s any general answer to the question of whether classification is a good or a bad thing. Some diagnoses are helpful, some of the time!

I spend a lot of time thinking about how systems like the D.S.M. might best be constructed and revised. One of the interesting developments with the D.S.M.-5 was that the American Psychiatric Association decided that values should explicitly be considered. A committee was set-up to try and ensure that only revisions that would on balance help those diagnosed would be included. Though the effectiveness of the committee might be debated, the fact that the committee existed is a great development. Some potential diagnoses might be no help to anyone anywhere (I’ve argued that prodromal personality disorders might be examples) and it is a good thing for such diagnoses to be excluded from the D.S.M.

EM: You are interested in the possible roles of service users in revising the D.S.M. and revamping the mental health field. What are some of your thoughts on that subject?

RC: As a researcher interested in how systems like the D.S.M. are developed, I’ve spent about a month reading D.S.M. committee minutes in the archives of the American Psychiatric Association. One of the things that I find most interesting is that so many very clever and mainly well-intentioned people put so much effort into revising the D.S.M.—and yet in each revision errors creep in. In part I think this is because the committees that revise the D.S.M. are insufficiently diverse, being made up almost exclusively of research psychiatrists and psychologists. The training, interests, and background assumptions that are common to such people make them very good at seeing certain types of problem, but make them vulnerable to missing others.

As an example, consider the D.S.M.-5 diagnostic criteria for phobia. In D.S.M.-IV diagnosed individuals had to recognize their fears as unreasonable. In D.S.M.-5 the fear merely has to be judged by the clinician to be out of proportion. I think the revision was a mistake. Consider what can now happen if someone develops rational fears on the basis of information that the diagnosing clinician lacks. Take a scientist working on avian flu whose studies lead her to the conclusion that a worldwide pandemic is imminent. She comes to develop rational fears about sick birds. Using D.S.M.-IV criteria she did not have a phobia, as she would not have considered her fears unreasonable. Using D.S.M.-5, if a clinician (who we will suppose knows nothing of these matters) judges her fear as being out of proportion, she can receive a diagnosis. This seems wrong.

I suggest that most likely the problem here arose because the committee assumed that clinicians always know more than service users. This is the sort of error that it is easy for doctors to make, but that service users, with their rather different assumptions and life experiences, would be less likely to overlook. Generalising, I think there are mistakes in the D.S.M. that could have been avoided if drafts had been checked by a more diverse body of readers.

EM: You write on the concepts of health, illness, and disease. What are some of your thoughts on those constructs?

RC: One of the things I’ve argued in my work is that “health” and “disease” are not purely factual, scientific notions. Science can tell us that someone’s body or mind works in a way that differs from the statistical norm, but it can’t show us whether any difference is best thought of simply a difference, or is a problem that might be appropriately treated (and so a “disorder”). I’ve argued that a difference can only be a disorder is it’s a bad thing. As such, it’s impossible to determine whether a difference needs “fixing” without thinking about questions related to “the good life.” Figuring out what should count as a disorder gets tied-up with questions about what kinds of people we want to be, and what kinds of communities we want to live in.

EM: What are your thoughts on the current, dominant paradigm of diagnosing and treating mental disorders and the use of so-called psychiatric medication to treat mental disorders in children, teens and adults?

RC: It’s often assumed that accepting the notion that mental distress falls into distinct “mental disorders” and advocating drug treatments must come as a package deal. I don’t think this needs to be the case. One might be suspicious of drugs while believing there are distinct types of mental disorder, or keen on drugs while thinking that mental distress is dimensional, or even meaningful.

The key question in deciding whether to take drug treatments is whether or not they seem to help people. Here, though, forming an opinion becomes very tricky, as there is good reason to think that the pharmaceutical industry manipulates the reported evidence concerning drug efficacy. As a consequence, it’s reasonable to suspect that many drugs may be less effective, and potentially more dangerous, than their manufacturers claim. These concerns need taking very seriously. On balance, though, I think that there is sufficient evidence to suggest that drugs do help people often enough for it to be worth giving them a go. So long as it was on a trial basis, and I could stop taking them if I found they weren’t helpful (and I recognise that with some medications this can be difficult), I’d give drugs a try.

EM: If you had a loved one in emotional or mental distress, what would you suggest that he or she do or try?

RC: As a philosopher, practical advice isn’t my strong point! That being said, I think a key word here is “distress.” I’d only suggest seeking any sort of help if there is actually a problem. If someone hears voices, or doesn’t like sex, or has no friends, then this is only a problem if it causes them harm.

In cases where someone is distressed and something needs to be done, I’ve been uniformly impressed by the advice and practical help offered by MIND In the U.K., MIND have links with advocates who have direct knowledge of local services. Those I’ve met have been very impressive, and I’d want their advice if I was accessing mental health services myself.